recognizing melanocytic lesions - patologi.com · (lentigo senilis, lentigo solaris, liver spot,...
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Recognizing Melanocytic Lesions
James E. Fitzpatrick, M.D. University of Colorado Health Sciences Center
No conflicts of interest to report
Pigmented Skin Lesions Pigmented keratinocyte neoplasias
– Solar lentigo – Seborrheic keratosis – Pigmented actinic keratosis (uncommon)
Melanocytic hyperactivity – Ephelides (freckles) – Café-au-lait macules
Melanocytic neoplasia – Simple lentigo (lentigo simplex) – Benign nevocellular nevi – Dermal melanocytoses – Atypical (dysplastic) nevus – Malignant melanocytic lesions
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Solar Lentigo (Lentigo Senilis, Lentigo Solaris, Liver Spot, Age Spot)
Proliferation of keratinocytes with ↑ melanin – Variable hyperplasia in number of melanocytes
Pathogenesis- ultraviolet light damage
Solar Lentigo
Older patients Light skin type Photodistributed Benign course Problem-
distinguishing form lentigo maligna
Note associated solar purpura
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Seborrheic Keratosis “Barnacles of Aging”
Epithelial proliferation Common- 89% of geriatric population Pathogenesis unknown
– Follicular tumor (best evidence) – FGFR3 mutations in a subset
Seborrheic Keratosis Clinical Features
Distribution- trunk>head and neck>extremities Primary lesion
– Exophytic papule with velvety to verrucous surface- “stuck on appearance”
– Color- white, gray, tan, brown, black Complications- inflammation, pruritus, and simulation of cutaneous malignancy Malignancy potential- none to low (BCC?)
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Seborrheic Keratosis
Seborrheic Keratosis-
skin tag-like variant
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Pigmented Seborrheic Keratosis
Inflamed Seborrheic Keratosis
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Café-au-Lait Spots
Subtle increase in number of melanocytes with increased melanin production Congenital or early childhood Distribution- trunk and proximal extremities Typically solitary Multiple lesions associated with NF
– Prepubertal child- 6 or more > 5 mm – Crowe’s sign
Café-au-Lait Spots in Patient with
Neurofibromatosis
+ Crowe sign = axillary freckling
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Simple Lentigo (Lentigo Simplex)
Lentiginous hyperplasia + melanocytic hyperplasia – Closely related to junctional nevus – May evolve into junctional nevus
Simple Lentigo (Lentigo Simplex) Clinical Features
May occur at any age May be single or multiple Distribution- skin or mucous membranes Primary lesion- tan to brown to black macule
usually measuring 5 mm or less Multiple lentigines
– Peutz-Jeghers -syndrome – Carney’s syndrome – LEOPARD syndrome – Centrofacial lentiginosis
Malignancy potential- no statistics
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Solitary Simple Lentigo
Centrofacial Lentiginosis
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Carney’’s Complex Lentigines
Atrial myxoma
Endocrinopathies
Labial melanotic macule
Genital lentigo
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Nevocellular Nevi (Moles, Melanocytic Nevi)
Growth patterns – Junctional nevus – Intradermal nevus – Compound nevus
Number of nevi (Caucasians) – 20 years of age = 20 nevi – Australian study- number peaks in 2nd & 3rd decade
Men = 43 nevi Women = 27 nevi
Nevocellular Nevi Clinical Features
Age of onset- infancy to adulthood Distribution- any skin surface including mucous membranes – Number of nevi increased on sun-exposed skin
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Junctional Nevus Clinical Features
Location anywhere- especially common on plantar and palmar surfaces
Size- variable, 1-5 mm Primary lesion
– Macule or subtle papule – Surface- typically smooth – Color- tan to brown to black
Junctional Nevus
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Intradermal Nevus Clinical Features
Location- head and neck most common Size- variable, most less than 6 mm Primary lesion
– Papule or nodule – Dome-shaped, papillated, pedunculated,
cerebriform – Color- skin-colored to tan to light brown
Intradermal Nevus
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Intradermal Nevus
Compound Nevus Clinical Features
Trunk and proximal extremities- most common Size- variable, most less than 6 mm Primary lesion
– Papule or nodule – Dome-shaped, papillated or pedunculated – Color- tan to brown to black
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Compound Nevus
Melanocytic Nevi Clinical and Histological Variants
Halo nevus Meyerson’s nevus Spitz nevus Pigmented spindle cell nevus Desmoplastic nevus Nevus spilus
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Multiple Halo Nevi
Halo Nevus
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Spitz Nevus
Multiple Spitz Nevi
Histologically difficult to differentiate from melanoma
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Nevus Spilus
Cosmetic Issues in Nevi
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Multiple Benign Nevi No “ugly duckling”
If you were going to take one off, which one would you choose (A, B, C, D, E)?
A
B
E
C
D
Nevocellular Nevi Treatment Options
Standard of care – Tangential (shave) biopsy – Punch biopsy – Excision biopsy
Outside of the standard of care – Electrodessication – Cryotherapy – Dermabrasion (exception- congenital nevus?) – Laser
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Recurrent Nevus
Courtesy- Loren Golitz, M.D.
Recurrent nevi are often asymmetric, show multiple colors, dark colors and irregular borders.
Recurrent Nevus after Electrodessication
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Congenital Nevi
Congenital Nevi
Congenital pigmented lesions- 2.5% of newborns Congenital nevi- 1% of newborns Congenital nevi > 10 cm- 1 in 20,000
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Congenital Nevi May be solitary or multiple May affect any cutaneous surface Primary lesion is 1 mm to huge
– Presence of dark hairs- no clinical significance Complications
– Head, neck, posterior midline- cranial and/or leptomeningeal melanocytosis
– Melanoma Associations- neurofibromatosis
Small (< 1.5 cm) Congenital Nevus
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Medium (1.5-19.9 cm) Congenital Nevus
Medium (1.5-19.9 cm) Congenital Nevus
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Medium (1.5-19.9 cm) and Multiple Small (< 1.5 cm) Congenital Nevi
Giant (≥ 20 cm) Congenital Nevus
with satellite lesions
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Melanoma arising in Medium Congenital Nevus
Blue Nevus
Definition- dermal proliferation of melanocytes that produce abundant melanin
Blue color- optical effect where longer wavelengths are absorbed and shorter wavelengths are reflect back
Other dermal melanocytoses – Mongolian spot – Nevus of Ota – Nevus of Ito
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The Tyndall effect
Blue Nevus Clinical Features
Congenital (1:3000) or acquired (4% of adults) Most common in Asians and whites, uncommon in blacks Primary lesion- blue to blue-gray to blue-white papule or nodule Size- 1 mm to 2 cm
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Blue Nevus Variants
Common blue nevus Cellular blue nevus Combined nevus Malignant blue nevus (very rare)
Multiple Common Blue Nevi
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Cellular Blue Nevus
Mongolian Spot
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Nevus of Ota
Dysplastic Nevus (Atypical Nevus, Clark’s Nevus, Nevus With Cytologic Atypia and Architectural Disorder)
Acquired melanocytic proliferation – Epidermal and/or dermal proliferation of cytologically
atypical nevomelanocytes – Abnormal growth pattern (architectural disorder)
Sporadic or familial Clinical importance
– Ten studies- 6.6%-70.3% of melanomas are contiguous with dysplastic nevi
– Familial dysplastic nevus syndrome- risk of melanoma approaches 100%
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Dysplastic Nevi Clinical Features
Males = Females Age of onset- usually apparent by 20 years Location- any cutaneous site especially trunk Number of lesions- solitary to hundreds Primary lesion
– Round to oval to irregular – Variegation in color- tans, brown, black, reds – Margins- often indistinct (fuzzy), pigment bleeds into
surrounding skin, irregular margins – Size- no limit
Atypical Nevus
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Atypical (dysplastic) Nevus
What is wrong with this nevus?
Larger than other nevi
More than one color
Asymmetric
Severely Atypical Nevus
Large
More than one color
Asymmetric
Irregular margins
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Multiple Atypical (Dysplastic) Nevi Which one is the “ugly duckling?
A
F E
D C
B
Familial Atypical Nevi
(FAMMM syndrome)
Numerous atypical nevi
History of melanoma and MM-situ
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Familial Atypical Nevi (FAMMM syndrome)
Oldest daughter (16 yo)
20 nevi upper chest
>100 total
Familial Atypical Nevi (FAMMM syndrome)
Youngest daughter
44 nevi on back and posterior arms
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Grim Reaper and Atypical Nevi
Malignant Melanoma Clinical Variants
Superficial spreading- 65% Nodular- 20% Lentigo maligna melanoma- 10% Acral lentiginous- 4% Desmoplastic- 1%
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Early Melanoma in-situ (Lentigo
Maligna)
Early Melanoma in-situ (Lentigo Maligna)
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Melanoma in-situ (Lentigo Maligna)
Melanoma in-situ (Lentigo Maligna)
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Melanoma in-situ (Lentigo Maligna)
Melanoma in-situ (Lentigo Maligna)
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Superficial Spreading Melanoma
Breslow level = 0.35 mm
Clark’s level II
Superficial Spreading Melanoma
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Superficial Spreading Melanoma
Breslow = 0.61 mm
Clark’s level III
Superficial Spreading Melanoma
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Superficial Spreading Melanoma with Nodule
Ulcerated Nodular Melanoma
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Superficial Spreading Melanoma with Nodule
Regressed Melanoma
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Acral Lentiginous Melanoma
Acral Lentiginous MM
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Desmoplastic Melanoma
Melanoma Non-dermatologists Dermatologists 6 of 6 2% 27% 5 of 6 10% 42%
4 of 6 26% 23% 3 of 6 33% 8%
2 of 6 22% - 1 of 6 7% -
J Am Acad Dermatol 14:555-560, 1986
Visual Diagnosis of Melanoma “Room for Improvement”
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Malignant Melanoma ABCDE Guidelines
A = Asymmetry B = Border irregularity (notches, pseudopods) C = Color variegation (black blue, brown, tan, white, gray, red) D = Diameter greater than 6 mm E = Evolution (change, bleeding)
The “Ugly Duckling”
Shave biopsy site
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The End